Indirect Fistula: A New Terminology for Cerebrospinal Fluid Fistula With Different 'Apparent Origin' and 'Real Origin'.

Fistulas are abnormal communications between body cavities. They can occur between the CNS and the extracranial space, presenting clinically as CSF leaks. Due to the variety of features, multiple classifications have been implemented to better study this pathology. A systematic review was conducted using the Scopus, Medline, and Web of Science databases. Observational studies such as cohort studies, case reports, case series, cross-sectional studies, systematic reviews, and publications that assess the classification of CSF leaks were included. The systematic review identified 29 publications that met the required criteria for inclusion. Although the primary focus of most of these publications was not on classification, they briefly mentioned it. The included publications describe classifications according to etiology, exiting flow pressure, anatomic site, and some new classification proposals. Of the 29 included studies, 11 referred to the appearance of CSF rhinorrhea or otorrhea with no relationship between the cause or site of origin and the site of the CSF leak. However, none of these publications names this situation. These results clearly indicate that a term for this circumstance needs to be established; none of the previously listed publications provide a name for this condition. This systematic review aims to demonstrate the necessity of implementing a new term to describe CSF leaks where the 'apparent origin' does not correspond to the 'real origin.' The results show no existing term that considers such cases; therefore, we propose the term 'Indirect Fistula' to designate these cases.

Accurate preoperative diagnosis of a Rathke cleft cyst with the aid of a novel classification for sellar cystic lesions and a diagnostic algorithm decision: Tools for differentiating cystic sellar lesions with a representative case.

Background: Rathke's cleft cyst (RCC) is a benign lesion in the sellar and suprasellar compartments. Similarly, pituitary adenomas can present with cystic morphology, making it a differential diagnosis when evaluating a patient with a cystic lesion in the sellar region. Surgical goals differ between RCCs and pituitary adenomas as the first can achieve remission of symptoms with cyst decompression in contrast to pituitary adenomas where complete resection would be the main goal. Imaging analysis alone may not be sufficient to define a preoperative surgical plan. The combination of imaging and conjoined use of validated tools may provide valuable insights to the clinician when defining a surgical approach. Case Description: We present a case of a 27-year-old male with a 3-month history of visual disturbances and headaches. Magnetic resonance imaging showed a cystic lesion in the sellar compartment with compression of nearby structures. The authors were able to accurately diagnose this sellar lesion as an RCC with the conjoined aid of two classifications proposed in the literature. Cyst evacuation was performed with relief of symptoms and improved visual outcomes at follow-up. Conclusion: While cystic adenomas can require total resection for cure, RCCs can show marked improvement with partial resection and evacuation of its contents. An accurate preoperative diagnosis can lead the surgeon to opt for the best surgical approach.

Subdural open drains as an effective and low-cost modality for the treatment of chronic subdural hematomas.

PURPOSE: We present a series that describes the presenting features and clinical outcomes in patients with CSDH treated with a standardised technique and an open-drain placement. METHODS: We reviewed the medical records of 155 consecutive patients at a single centre who underwent CSDH evacuation by placing burr holes, accompanied by intraoperative irrigation and a subdural Penrose drain between 2014 and 2018. RESULTS: The mean age was 65.9 years, 81.9% were males. The most common clinical characteristics were an altered mental state (21.9%) and headache (12.9%). It was necessary to perform a second surgical intervention due to the evidence in the postoperative tomography of a residual hematoma in 10.3% of the cases; there were 2 cases of recurrence in 6 months (1.3%). Pneumonia (6.5%) and seizures (5.8%) were the most frequent medical complications. Intracranial infections accounted for 1.9%, and the mortality rate was 6.4% of cases. CONCLUSIONS: We provided our experience with a low-cost and less-commonly used technique in the management of CSDH. This technique showed similar recurrence, mortality and intracranial infection rates to those reported in the literature for closed drainage systems. Additional studies will be required to assess this technique.

3D-Printed Endoport vs. Open Surgery for Evacuation of Deep Intracerebral Hemorrhage.

BACKGROUND: Large-sized clinical trials have failed to show an overall benefit of surgery over medical treatment in managing spontaneous intracerebral hemorrhages (ICH); less invasive techniques have shown to decrease brain injury caused by surgical manipulation in the standard open approach improving the clinical outcomes of patients. Thereby, we propose a low-cost 3D-printed endoport for a less invasive ICH evacuation. In this study, the authors compare the clinical outcomes of early surgical evacuation using a 3D-printed endoport vs. a standard open surgery (OS). METHODS: A retrospective analysis was conducted comparing patients who underwent early evacuation of a deep hypertensive ICH through an endoport vs. OS at a single center from August 2017 to March 2019. Demographic, clinical, and radiologic data were reviewed. The primary outcomes were the 90-day post-stroke functional outcome and mortality. RESULTS: A total of 36 patients were included. The two cohorts (18 endoport; 18 OS) showed no statistically significant differences in demographic, clinical, and radiologic characteristics, including median admission hemorrhage volume, Glasgow Coma Scale, and ICH scores. At 90-day post-stroke, 44% of patients in the endoport group and 17% in the OS group had a favorable functional outcome (mRS 0-3) (p = 0.039); moreover, the endoport group showed lower mortality (33% vs. 72%, p = 0.019). CONCLUSIONS: This study suggests that an endoport-assisted ICH evacuation may have better functional outcomes and lower mortality than OS. The proposed device could provide a safe, low-cost alternative for ICH's surgical treatment. More rigorous research is hence needed to assess the potential benefits of this technique.

Pelvimetry by reformatted computed tomography in 290 female pelvis: morphometric variations regarding age / Pelvimetría mediante tomografía computadorizada reformada sobre 290 pelvis femeninas: variaciones morfométricas de acuerdo a la edad

The Mexican government passed a new reform of article 11 of the General Law in 2014 regarding Women's Access to a Life Free of Violence, which states that a cesarean section may not be performed if a vaginal birth is viable. Cesarean sections are excessively indicated in Northen Mexico, using the diagnosis of cephalopelvic disproportion due to a narrow pelvis. Currently, there is no standardized morphometry of the female pelvis in a Mexican population to establish adequate diagnostic parameter. Our study measures the pelvic diameters of the birth canal using abdominopelvic computed tomography (CT). Two hundred and ninety CT from Mexican women between the ages of 18 and 50 were collected and 3D reformatted in order to morphologically measure the pelvic diameters of clinical relevance. Measurements were conducted by two diagnostic imaging specialists. The mean and standard deviation of the measured diameters were: anatomical conjugate diameter (ACD) 11.65±0.99 cm, the obstetric conjugate diameter (OCD) 11.73±0.98 cm, diagonal conjugate diameter (DCD) 12.49±0.98 cm and Interspinous distance (ISD) 10.41±0.78 cm. Significant differences were found in all four mean diameters in between the 20­29 age groups versus the >40, as well as between the 30­39 groups versus the >40. Our study shows that as Mexican women get older, the mean pelvic diameters become narrower.

El Gobierno mexicano aprobó una nueva reforma del artículo 11 de la Ley General del 2014, relativa al acceso de las mujeres a una Vida Libre de Violencia, que establece que una cesárea no se puede realizar si un parto vaginal es viable. Los partos por cesárea son indicados excesivamente en el norte de Mexico, con el diagnóstico de desproporción céfalo-pélvica debido a una estrechez de la pelvis. Actualmente, no existe una morfometría estandarizada de la pelvis femenina en una población mexicana para establecer parámetros de diagnóstico adecuado. Nuestro estudio mide los diámetros pélvicos del canal de parto mediante tomografía compudotarizada (TC) abdomino-pélvica. Se usaron 290 TC de mujeres mexicanas entre 18 y 50 años, los que fueron reformateados en 3D para medir morfológicamente los diámetros pélvicos de relevancia clínica. Las mediciones fueron realizadas por dos especialistas en diagnóstico por imagen. La Media y DE de los diámetros medidos fueron: diámetro anatómico conjugado (DAC) 11,65±0,99 cm, diámetro obstétrico conjugado (DOC) 11,73±0,98 cm, diámetro diagonal conjugado (DDC) 12,49±0,98 cm y distancia interespinosa (DIE) 10,41±0,78 cm. Se encontraron diferencias significativas en las Medias de los cuatro diámetros entre los grupos de 20­29 años de edad frente a las >40 años, así como entre los grupos de 30­39 años frente a los >40 años. Nuestro estudio muestra que a medida que las mujeres mexicanas avanzan en edad, los diámetros pélvicos medios son más estrechos.